Social security is authorized to collect your information under sections 1836 1840 and 1872 of the social security act as amended 42 u s c.
Social security part b employer form.
If you re an employer without an hours bank.
Your name date of birth and.
The social security act as amended 42 u s c.
If you are already enrolled in medicare part a and you would like to enroll in part b please complete form cms 40b application for enrollment in medicare part b medical insurance if you are applying for medicare part b due to a loss of employment or group health coverage you will also need to complete form cms l564 request for employment information.
Once section a is completed give this form to your employer to complete section b.
Please call us at 1 800 772 1213 tty 1 800 325 0778 monday through friday between 8 a m.
One portion is completed by you and the other is completed by your employer or your spouse s employer.
The employer completes all of section b.
The benefit you receive from us.
A social security benefit verification letter includes.
Visit faq ssa gov or call social security to free at 1 800 772 1213 tty 1 800 325 0778 for more information.
Once section b has been completed by your employer return this form along with your part b application to your local social security office.
Social security and the centers for medicare medicaid services cms need your information to determine if you.
If you live in puerto rico you will not receive medicare part b medical insurance automatically.
To sign up please call our toll free number at 1 800 772 1213 tty 1 800 325 0778 you also may contact your local social security office.
1395o 1395s and 1395ii for your enrollment in medicare part b.
Social security and the centers for medicare medicaid services cms need your information to determine if you re entitled to part b.
Your employer doesn t need to sign section b of the cms l564 form.
If you are an individual representative payee with a my social security account you should check out our new representative payee portal.
Once section b has been completed by your employer return this form along with your part b application to your local social security office.
It lets you conduct your own business or manage direct deposit wage reporting proof.
Many forms must be completed only by a social security representative.
The form you are looking for is not available online.
1395o 1395s and 1395ii for your enrollment in medicare part b.
What is form cms l564.
Form cms l564 is an employment information form from the social security administration ssa.
If you re an employer without an hours bank arrangement complete the section called for employer group health plans only.
You will need to sign up for it during your initial enrollment period or you will pay a penalty.
It s used in conjunction with form cms 40b when you apply for medicare part b during a special enrollment period sep.
